Provider Demographics
NPI:1821190620
Name:DICKMAN, DANIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:DICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7000
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-7000
Mailing Address - Country:US
Mailing Address - Phone:304-347-1290
Mailing Address - Fax:304-347-1397
Practice Address - Street 1:1201 WASHINGTON ST E
Practice Address - Street 2:SUITE 108
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1834
Practice Address - Country:US
Practice Address - Phone:304-347-4600
Practice Address - Fax:304-347-4621
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0053040000Medicaid
F17391Medicare UPIN
WVDI0689844Medicare ID - Type Unspecified